,書式設定,書式設定,第 2,第 3,第 4,第 5,*,Saiseikai,Yokohama-City,Eastern,Hospital,Saiseikai,Yokohama-City,Eastern,Hospital,書式設定,書式設定,第 2,第 3,第 4,第 5,*,Current strategy of,retrograde wire for CTO,Toshiya Muramatsu MD,Division of Cardiology,Saiseikai Yokohama-City Eastern Hospital,Strategic Changes,Retrograde approach,25.1%,Seesaw wiring,33.2%,GW 4.0 2.4,(max 10),Total 46.4%,Seesaw wiring,43.1%,Conquest trial,N=116,July,2003-March,2004,J-CTO,N=378,April,2006-December,2007,2 years later,Approach site(Overall),femoral,80.8%97.4%,radial5.1%1.8%,brachial,14.2%0.9%,Single site puncture35.4%49.5%,Dual site puncture64.6%50.5%,GC size,6.9,0.5 Fr7.1 Fr,GC size(contralateral),6.0,1.0 Fr,Contrast amount(cc)312 155365 146,Fluoro scopic time(min)52.9 37.850.9 35.7,Total procedural time(min)123.3 65.7,Emergent procedure1.8%,Basic Procedural Characteristics,J-CTOConquest,N=451,N=337,Procedural Success,90.0%,89.8%,90.5%,initial success87.9%),88.8%,Conquest trial,Single wire94.0%277 13343.2 31.5,(54.6%),Seesaw82.1%339 15350.2 29.3,(20.3%),Retrograde93.3%436 203.76.4 45.6,(11.9%),Seesaw+Retrograde66.0%,423 15097.9 9.0,(12.7%),N=378,Proc.success,(%DS 3 times)4.2%,Stent thrombosis 0%,Stroke0%,In-hospital outcomes,N=451,Perforation4.4%(18/408),tanponade0.5%(2/408),Treatment,balloon compression2.7%(11/408),drainage0.2%(1/408),coil embolization0.5%(2/408),covered stent0%(0/408),surgery0%(0/408),Emergent PCI0.9%(4/451),Emergent CABG0%(0/451),Blood transfusion2.0%(9/451),Access site surgery0.4%(2/451),GI bleeding0.2%(1/451),Complications,Retrograde Wire,Technique,Guidewire cross from CTO distal site,through collaterals channels supplied,from contrallateral vessel.,Indication of Retrograde Approach,Failed Antegrade Approach,Hopeless Antegrade Approach,Unknown Entry Point,Long CTO(40mm),Heavy Calcium,RCA Bent Point CTO,Ante GW into Subintimal Space,Good Collaterals,Straight,Big,Visible,Systems of retrograde technique,Retrograde guiding catheter,short GC(85-90cm),7 or 8F,good back-up,Retrograde guidewire,floppy type GW(fielder,whisper,runthrough etc),Retrograde balloon,long and small balloon(150cm,1.25mm),23atm,GW Structure,X-treme,Fielder FC,Fielder,16cm Radio-opaque spring coil,0.009,0.014,PTFE Coating,Stainless Steel Core,16cm Polymer Sleeve&Hydrophilic Coating,11cm Spring Coil,3cm Radio-opaque Coil,0.014,PTFE Coating,Stainless Steel Core,20cm Polymer Sleeve&Hydrophilic Coating,12cm Spring Coil,3cm Radio-opaque Coil,0.014,PTFE Coating,22cm Polymer Sleeve&Hydrophilic Coating,Stainless Steel Core,3cm,1cm,Retro GW Structure,Fielder FC,Fielder,X-treme,Standrad type wire using retrograde,Good support in the channel,Straightened the collateral channel,Small guidewire tip,Approach for thinner collateral channel,Less support,Careful manipulate making dissection,My strategy of Retrograde Technique,Good support,F Guiding Catheter,Straight collateral is good root for navigate GW,If possible,GW introduce to true lumen retrogradly,If impossible,、,change to CART technique,Sometimes,Reverse CART is useful,Septal dilatation is not always necessary,Ryujinn OTW is good balloon for septal dilatation,Careful to contrallateral guiding catheter wedge,thrombus,ischemia.,Benefit and Risk of Collateral way,Straight,Risk of perforation,Risk of Tamponade,Visibility,Length,Septal,Small,Small,FairGood,Moderate,Epicardial,Big,Big,Good,Long,Retrograde Approach for LAD CTO,1.Retrograde GW crossing through collateral channel,2.Retro GW enter into subintima space from distal fibrous cap,3.Antegrade GW also enter in the subintima space from proximal site,4.Retro balloon deliver into subintima sapce and dilate,5.Dilating subintima space makes a channel connection between ante and retro GW,6.Ante GW cross through subintimal to true distal lumen,CART technique,CART technique,CART,tecqnique,Pseudo,lumen,True,lumen,Retrograde dilatation of the pseudo lumen,Antegrade puncture,CART,tecqnique for LAD CTO,1.Retrograde GW crossing through collateral channel,2.Retro GW enter into subintima space from distal fibrous cap,3.Antegrade GW also enter in the subintima space from proximal site,4.Antegrade balloon deliver into subintima sapce and dilate,5.Dilating subintima space makes a channel connection between ante and retro GW,6.Retro GW cross through subintimal to true proximal lumen,Reverse,CART technique,Reverse CART,tecqnique,Pseudo,lumen,True,lumen,Antegrade dilatation of the pseudo lumen,Retrograde puncture,Easy insert balloon from ante CTO site,No need of retro balloon through the collateral channel to CTO vessel,no chance of complication related collateral,-dissection,spasm,perforation-,exhaust time during balloon crossing collateral,Possible using IVUS,Anchoring retro GW by ante ballooning,anchor balloon makes a easy crossing,microcatheter,Ballooning into big vessel of reverse CART means safer than that in smaller vessel of retro ballooning,Benefit of Reverse CART technique,Complication,Donor artery ischmia,spasm or thrombosis,Channel dissection,Channel rupture,Entrapment of retrograde